Lawrence P. Goldstick, MD, is an associate professor of neurology at the University of Cincinnati Waddell Center for Multiple Sclerosis in Cincinnati, Ohio. He is also clinical associate professor at Boonshoft School of Medicine at Wright State University in Dayton, Ohio, where he is past director of the multiple sclerosis clinic. He also is past medical and research director of the Ohio Center for Multiple Sclerosis Treatment and Research, certified by the Consortium of Multiple Sclerosis Centers, and the director of the Ohio Center for Neuroscience Research in Dayton Ohio.

Dr. Goldstick specializes in multiple sclerosis (MS)/neuroimmunology, but also has expertise in epilepsy, Parkinson’s disease, Alzheimer’s disease, and clinical neurophysiology, His primary research has involved MS and he served as primary and sub investigator on multiple clinical trials (over 80 trials) in all the above areas as well as stroke and migraine. He has been involved in basic science neurophysiologic research involving Parkinson models in rats and microbiological studies of heavy metal intoxication in slime mold models.

He is actively involved in the Dayton neurological community, and has served as director of the EEG Laboratory and a director of the Carotid Vascular Laboratory at Good Samaritan Hospital, director of the EEG and Neurovascular Laboratory at Miami Valley Hospital. He serves on the Medical Scientific Advisory Committee for the Alzheimer’s Association and the Board of Directors for the Ohio Valley Chapter of the National Multiple Sclerosis Society, and is a member of the American Academy of Neurology and the American Medical Association. Dr. Goldstick is Board Certified in Neurology and Psychiatry and by the American Board of Clinical Neurophysiology

Dr. Goldstick graduated cum laude from the University of Michigan in Ann Arbor, Michigan, with a Bachelor of Science degree in microbiology. He then earned his medical degree at Michigan State University in East Lansing, Michigan. He completed his neurology residency at the University of Cincinnati in Cincinnati, Ohio, where he was named Chief Resident, and went on to complete a special fellowship in electroencephalography, epilepsy, evoked potentials, and clinical neurophysiology at the Cleveland Clinic Foundation, Department of Neurology in Cleveland, Ohio.

He has published multiple articles and abstracts in Neuropathology and Experimental Neurology, Neurology, EEG and Clinical Neurophysiology, Epilepsy, The Journal of Multiple Sclerosis and Related Disorders. Dr. Goldstick has also submitted a grant with The University of Dayton through PCORI (Patient Centered Outcome Research Institute) for the Study of patient, Caregiver, and Neurologist Perceptions and Use of Web-Based Information in Multiple Sclerosis Treatment Decision Making. He has given presentations at the Academy of Neurology, The National Institutes of Health, The Cleveland Clinic, The University of Cincinnati, and multiple sites.

■ Licensed in their home countries, many medical workers find only menial jobs in the U.S. One program helps them re-enter the field they love.

Dr. Maria Angelica Montenegro practiced more than five years as a family physician in Colombia before moving to the United States in 2004 after her mother was diagnosed with breast cancer in a New York hospital.

She looked into getting a U.S. medical license, but found the process complex and confusing. So she sold sunglasses and baby-sat to pay the bills -- all the while dreaming of the day she could return to her passion of practicing medicine.

"I'm a doctor from my country, and I want to do it here. I love medicine. I love my patients," Dr. Montenegro said. "I don't care if I have to go to Alaska to practice medicine, I want to do it."

Dr. Montenegro is among the unknown numbers of untapped foreign-trained physicians living in the U.S. Many are either unemployed or work jobs far below their education level.

They are taxi drivers, delivery people, housekeepers and restaurant workers. There are thousands of examples, including a Russian physician who was working construction and a Yemeni doctor who was a parking garage attendant, said Dr. Jose Ramón Fernández-Peña, founder and director of the Welcome Back Initiative. The program helps foreign-trained health professionals enter the U.S. health care work force through nine centers nationwide.

Since the initiative began in San Francisco in 2001, Welcome Back centers have helped 11,347 health professionals from 152 countries. Thirty-six percent of those are physicians, 42% are nurses, 13% are dentists and 9% are other health professionals.

Many come to the U.S. hoping to re-enter medical practice but find the process difficult and take whatever jobs they can to support their families. Sixty-six percent of program participants aren't working in health care when they come to one of the centers, Dr. Fernández-Peña said.

The loss of professional identity can be disillusioning. "They may be the only physician or social worker in their community," he said. "Then they come here and suddenly they are the janitor or the taxi driver. That weighs very heavily on a person."

Barriers to practice

Dr. Fernández-Peña was a family physician in Mexico City before moving to the U.S. in 1985 to attend New York University, where he received a master's degree in health policy and management. He checked into getting a U.S. medical license. "What I found was a lot of conflicting information," he said.

Now an associate professor at San Francisco State University, he has made a career in academics and administration. But along the way, he met many foreign-trained health professionals who expressed similar frustrations.

"They had the skills. They had the language. They knew the population. They just did not have the American license," he said. "Nobody really knows where to start."

Immigrant health professionals may face several barriers to obtaining a U.S. license, he said. The process often is confusing and time-consuming.

"Most of our participants work two, sometimes three, jobs," he said. "They don't have the time or money to take extra classes to learn English or study for exams."

Welcome Back centers offer help in many forms, including study groups, accelerated English-language classes, assistance navigating the steps to licensure, and financial aid for exams and study materials, said Manuela Raposo, director of the Rhode Island Welcome Back Center in Providence. Centers also link participants to volunteer opportunities at local clinics and hospitals to give them experience working in the U.S. health care system.

The path to a license

Foreign-trained physicians wanting to practice in the U.S. must seek certification from the Educational Commission for Foreign Medical Graduates. That includes passing two steps of the U.S. Medical Licensing Examination. Once certified, they must complete residency training at a U.S. institution, regardless of their years of experience abroad.

Those wanting to specialize also must redo specialty training such as fellowships. "That is something that is very difficult for some physicians, especially those who have been practicing for many years," Raposo said.

Dr. Ericka Olivera, a student at the Rhode Island center, was a family physician in Colombia before moving to the U.S. with her fiancé in 2005. She has been unemployed since but is working toward her medical license. She has passed the first exam of the USMLE and will take two more exams in September.

In the meantime, she volunteers at a free clinic that serves a largely Latino population. "Most of them don't speak English, so I can help with that," she said.

The New York Welcome Back Center helped Dr. Montenegro get training and a job as a phlebotomist while she studies for the USMLE. She said it is difficult to relearn everything eight years after completing medical school. "You have to remember everything you do in your career," she said.

While Drs. Olivera and Montenegro are determined to practice as physicians in the U.S., many foreign-trained doctors choose not to go through the rigorous U.S. licensing process, Dr. Fernández-Peña said. Instead, they pursue options such as becoming a registered nurse, respiratory therapist or physician assistant. Others go into academics or research.

Of the 4,022 physicians involved with the Welcome Back Initiative, only about 100 have entered residency training. "Large portions pursue other options," he said.

Increasing diversity

Welcome Back centers typically partner with community colleges or universities and receive a mix of public and private funding. The New York Center, for example, is funded by the New York Dept. of Small Business Services and the division of adult and continuing education at LaGuardia Community College.

"In these challenging economic times, we are actively looking for funds to expand and sustain our services," said John Hunt, the center's acting director. "The community response has been overwhelming."

In May, Dr. Fernández-Peña was honored by President Obama as a Champion of Change for his work with the initiative. The same month, he accepted the E Pluribus Unum Award from the Migration Policy Institute, a Washington-based nonprofit focusing on migration and refugee policies.

"For us, this whole question of brain waste has long been an issue," said Michelle Mittelstadt, MPI director of communications. "These people are coming to this country already armed with professional credentials, and they are unable to use them."

By helping health professionals become licensed, the centers help improve access to care in medically underserved areas and increase diversity in the health care work force, she said.

"Having those who speak the language and have the cultural competencies is important," Mittelstadt said. "The health care system is already taxed and will be taxed even more as health reforms move forward. This is about taking advantage of the pool of people already in this country."

The program has nine centers nationwide that provide assistance to foreign-trained health professionals seeking credentials to work in the United States.

Boston - Bunker Hill Community College Denver - Spring Institute for Intercultural Learning Des Moines, Wash. - Highline Community College New York - LaGuardia Community College Providence, R.I. - Dorcas Place San Antonio - Alamo Community College District San Diego - Grossmont College San Francisco - City College of San Francisco Silver Spring, Md. - Montgomery County Dept. of Health and Human Services

About ECFMG

Overview

ECFMG is a world leader in promoting quality health care—serving physicians, members of the medical education and regulatory communities, health care consumers, and those researching issues in medical education and health workforce planning.

International medical graduates (IMGs) comprise one-quarter of the U.S. physician workforce. Certification by ECFMG is the standard for evaluating the qualifications of these physicians before they enter U.S. graduate medical education (GME), where they provide supervised patient care. ECFMG Certification also is a requirement for IMGs to take Step 3 of the three-step United States Medical Licensing Examination (USMLE) and to obtain an unrestricted license to practice medicine in the United States.

ECFMG provides other programs for IMGs pursuing U.S. GME, including those that assist them with the process of applying for U.S. GME positions; and that sponsor foreign nationals for the J-1 visa for the purpose of participating in such programs. We offer a verification service that allows GME programs, state medical boards, hospitals, and credentialing agencies in the United States to obtain primary-source confirmation that their IMG applicants are certified by ECFMG. The ECFMG Certificate Holders Office (ECHO) provides support and service to ECFMG-certified physicians as they plan their medical careers.

ECFMG partners with the National Board of Medical Examiners (NBME) in administering the Step 2 Clinical Skills (CS) component of USMLE, a requirement for IMGs and for graduates of U.S. and Canadian medical schools who wish to be licensed in the United States or Canada. Through this collaboration, ECFMG uses its experience in assessment to ensure that all physicians entering U.S. GME can demonstrate the fundamental clinical skills essential to providing safe and effective patient care under supervision.

Through more than five decades of certifying IMGs, ECFMG has developed unparalleled expertise on the world’s medical schools, the credentials they issue to their graduates, and the verification of those credentials. ECFMG has expanded this expertise to include credentials related to postgraduate training and registration/licensure through its primary-source credentials verification service for international medical regulatory authorities. And now, through the Electronic Portfolio of International Credentials (EPICSM), we are bringing this expertise to individual physicians and the entities that license, train, educate, and employ them.

ECFMG’s commitment to promoting excellence in international medical education led to the establishment of its nonprofit foundation, the Foundation for Advancement of International Medical Education and Research(FAIMER). FAIMER has assumed responsibility for, and expanded upon, ECFMG’s programs for international medical educators and ECFMG’s research agenda. Through FAIMER, ECFMG offers training in leadership and health professions education; creates and maintains data resources on medical education worldwide; and conducts research on international medical education programs, physician migration, and U.S. physician workforce issues.

Path to United States Practice Is Long Slog to Foreign Doctors

Sajith Abeyawickrama, who came in 2010 from Sri Lanka, teaches exam prep on genetics at Kaplan Medical in Newark, N.J. CreditKarsten Moran for The New York Times

Thousands of foreign-trained immigrant physicians are living in the United States with lifesaving skills that are going unused because they stumbled over one of the many hurdles in the path toward becoming a licensed doctor here.

The involved testing process and often duplicative training these doctors must go through are intended to make sure they meet this country’s high quality standards, which American medical industry groups say are unmatched elsewhere in the world. Some development experts are also loath to make it too easy for foreign doctors to practice here because of the risk of a “brain drain” abroad.

But many foreign physicians and their advocates argue that the process is unnecessarily restrictive and time-consuming, particularly since America’s need for doctors will expand sharply in a few short months under President Obama’s health care law. They point out that medical services cost far more in the United States than elsewhere in the world, in part because of such restrictions.

The United States already faces a shortage of physicians in many parts of the country, especially in specialties where foreign-trained physicians are most likely to practice, like primary care. And that shortage is going to get exponentially worse, studies predict, when the health care law insures millions more Americans starting in 2014.

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The new health care law only modestly increases the supply of homegrown primary care doctors, not nearly enough to account for the shortfall, and even that tiny bump is still a few years away because it takes so long to train new doctors. Immigrant advocates and some economists point out that the medical labor force could grow much faster if the country tapped the underused skills of the foreign-trained physicians who are already here but are not allowed to practice. Canada, by contrast, has made efforts to recognize more high-quality training programs done abroad.

“It doesn’t cost the taxpayers a penny because these doctors come fully trained,” said Nyapati Raghu Rao, the Indian-born chairman of psychiatry at Nassau University Medical Center and a past chairman of the American Medical Association’s international medical graduates governing council. “It is doubtful that the U.S. can respond to the massive shortages without the participation of international medical graduates. But we’re basically ignoring them in this discussion and I don’t know why that is.”

Consider Sajith Abeyawickrama, 37, who was a celebrated anesthesiologist in his native Sri Lanka. But here in the United States, where he came in 2010 to marry, he cannot practice medicine.

Instead of working as a doctor himself, he has held a series of jobs in the medical industry, including an unpaid position where he entered patient data into a hospital’s electronic medical records system, and, more recently, a paid position teaching a test prep course for students trying to become licensed doctors themselves.

For years the United States has been training too few doctors to meet its own needs, in part because of industry-set limits on the number of medical school slots available. Today about one in four physicians practicing in the United States were trained abroad, a figure that includes a substantial number of American citizens who could not get into medical school at home and studied in places like the Caribbean.

But immigrant doctors, no matter how experienced and well trained, must run a long, costly and confusing gantlet before they can actually practice here.

The process usually starts with an application to a private nonprofit organization that verifies medical school transcripts and diplomas. Among other requirements, foreign doctors must prove they speak English; pass three separate steps of the United States Medical Licensing Examination; get American recommendation letters, usually obtained after volunteering or working in a hospital, clinic or research organization; and be permanent residents or receive a work visa (which often requires them to return to their home country after their training).

The biggest challenge is that an immigrant physician must win one of the coveted slots in America’s medical residency system, the step that seems to be the tightest bottleneck.

That residency, which typically involves grueling 80-hour workweeks, is required even if a doctor previously did a residency in a country with an advanced medical system, like Britain or Japan. The only exception is for doctors who did their residencies in Canada.

The whole process can consume upward of a decade — for those lucky few who make it through.

“It took me double the time I thought, since I was still having to work while I was studying to pay for the visa, which was very expensive,” said Alisson Sombredero, 33, an H.I.V. specialist who came to the United States from Colombia in 2005.

Dr. Sombredero spent three years studying for her American license exams, gathering recommendation letters and volunteering at a hospital in an unpaid position. She supported herself during that time by working as a nanny. That was followed by three years in a residency at Highland Hospital in Oakland, Calif., and one year in an H.I.V. fellowship at San Francisco General Hospital. She finally finished her training this summer, eight years after she arrived in the United States and 16 years after she first enrolled in medical school.

Mr. Abeyawickrama was an anesthesiologist in Sri Lanka.CreditKarsten Moran for The New York Times

Only 118 of those doctors, he said, have successfully made it to residency.

“If I had to even think about going through residency now, I’d shoot myself,” said Dr. Fernández-Peña, who came to the United States from Mexico in 1985 and chose not even to try treating patients once he learned what the licensing process requires. Today, in addition to running the Welcome Back Initiative, he is an associate professor of health education at San Francisco State.

The counterargument for making it easier for foreign physicians to practice in the United States — aside from concerns about quality controls — is that doing so will draw more physicians from poor countries. These places often have paid for their doctors’ medical training with public funds, on the assumption that those doctors will stay.

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“We need to wean ourselves from our extraordinary dependence on importing doctors from the developing world,” said Fitzhugh Mullan, a professor of medicine and health policy at George Washington University in Washington. “We can’t tell other countries to nail their doctors’ feet to the ground at home. People will want to move and they should be able to. But we have created a huge, wide, open market by undertraining here, and the developing world responds.”

About one in 10 doctors trained in India have left that country, he found in a 2005 study, and the figure is close to one in three for Ghana. (Many of those moved to Europe or other developed nations other than the United States.)

No one knows exactly how many immigrant doctors are in the United States and not practicing, but some other data points provide a clue. Each year the Educational Commission for Foreign Medical Graduates, a private nonprofit, clears about 8,000 immigrant doctors (not including the American citizens who go to medical school abroad) to apply for the national residency match system. Normally about 3,000 of them successfully match to a residency slot, mostly filling less desired residencies in community hospitals, unpopular locations and in less lucrative specialties like primary care.

Over the last five years, an average of 42.1 percent of foreign-trained immigrant physicians who applied for residencies through the national match system succeeded. That compares with an average match rate of 93.9 percent for seniors at America’s mainstream medical schools.

Mr. Abeyawickrama, the Sri Lankan anesthesiologist, has failed to match for three years in a row; he blames low test scores. Most foreign doctors spend several years studying and taking their licensing exams, which American-trained doctors also take. He said he didn’t know this, and misguidedly thought it would be more expeditious to take all three within seven months of his arrival.

“That was the most foolish thing I ever did in my life,” he says. “I had the knowledge, but I did not know the art of the exams here.”

Even with inadequate preparation, he passed, though earning scores too low to be considered by most residency programs. But as a testament to his talents, he was recently offered a two-year research fellowship at the prestigious Cleveland Clinic, starting in the fall. He is hoping this job will give residency programs reason to overlook his test scores next time he applies.

“Once I finish my fellowship in Cleveland, at one of the best hospitals in America, I hope there will be some doors opening for me,” he said. “Maybe then they will look at my scores and realize they do not depict my true knowledge.”

The residency match rate for immigrants is likely to fall even lower in coming years. That is because the number of accredited American medical schools, and therefore United States-trained medical students, has increased substantially in the last decade, while the number of residency slots (most of which are subsizided by Medicare) has barely budged since Congress effectively froze residency funding in 1997.

Experts say several things could be done to make it easier for foreign-trained doctors to practice here, including reciprocal licensing arrangements, more and perhaps accelerated American residencies, or recognition of postgraduate training from other advanced countries.

In the United States, some foreign doctors work as waiters or taxi drivers while they try to work through the licensing process. Others decide to apply their skills to becoming another kind of medical professional, like a nurse practitioner or physician assistant, adopting careers that require fewer years of training. But those paths present barriers as well.

The same is true for other highly skilled medical professionals.

Hemamani Karuppiaharjunan, 40, was a dentist in her native India, which she left in 2000 to join her husband in the United States. She decided that going back to dentistry school in the United States while having two young children would be prohibitively time-consuming and expensive. Instead, she enrolled in a two-year dental hygiene program at Bergen Community College in Paramus, N.J., which cost her $30,000 instead of the $150,000 she would have needed to attend dental school. She graduated in 2012 at the top of her class and earns $42 an hour now, about half what she might make as a dentist in her area.

The loss of status has been harder.

“I rarely talk about it with patients,” she said. When she does mention her background, they usually express sympathy. “I’m glad my education is still respected in that sense, that people do recognize what I’ve done even though I can’t practice dentistry.”

A version of this article appears in print on August 12, 2013, on Page A1 of the New York edition with the headline: Path to United States Practice Is Long Slog to Foreign Doctors. Order Reprints| Today's Paper|Subscribe

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